Choice and Change


"Thoughts always reflect themselves in behavior. As humans, we are often contradictory - we say one thing and do another. If we want to change our behavior, we need to notice our actions as see if we can uncover the belief that led to the response." Margaret Wheatley, Turning to One Another


"If you get on the wrong train, every stop is the wrong stop". Unknown author.


Factors Affecting Change

People need understanding of why a choice is good before they will be willing to participate in change (Krummel et al, 2002; Manne et al, 2002) Turning understanding into change depends on many factors, including: aversion to health risks, value of future health versus competing choices such as wealth or lifestyle, information sources, and advertising and marketing.


Understanding is only part of the story, however: people with addictions struggle to change their behaviours despite knowing how their choices harm themselves and others.


Perceived risk is a subjective assessment of personal risk, based on an individual's interpretation of epidemiological and other data, and even when it is understood, people sometimes prefer to enjoy current benefits without thinking of future health costs. "You're only young once" is a common statement. Social support networks (social capital) can have a big influence on change. People are also influenced by external conditions - antimalarial bed nets may not be used due to availability and affordability.


Behviour Modification

SMART Goals:

Specific, Measurable, Achievable, Relevant, and Timely

Shape your behaviour: start small and build

stimulus control: identify events, situations, and people that elicit the unhealthy behaviour

reinforcement management


30% of people in EtOH detox centres have a diagnosable anxiety disorder;


Motivating People to Not Get Sick

"I want you to work really hard for two weeks, and I won't throw you down the stairs"

is very different than

"I'll give you 500 dollars"


Behaviour is all about negotiation; it's their perspective


Supporting Change

You cannot push anyone up a ladder unless they be willing to climb themselves. - Andrew Carnegie


Our choices have a big role to play in how our lives turn out, but it can be tough sometimes to both figure out the 'right' thing to do, and then do it. Health care providers have a big role to play in helping people decide on the best course of action and then follow through with it. Effective members of the health care team have skills in behavioural support, working collaboratively so as to deliver consistent messages.

Methods of supporting change include:


Reasons for Low Adherence

Intervention only works when you have control" - M. Vallis

Baserate for medication adherence is 50% McDonald, JAMA, (2002) 288:2868-9.

Mitka, JAMA, 2007, DASH

Woolf, JAMA, 2008 - 35% of all death

Reeves Rafferty Arch Int Med 2005; 165:854-7

Change is hard. Healthy behaviour has become abnormal.

avg caloric intake has gone up only a small amount; its the decrease in energy expenditure that is instead behind the obesity epidemic.


Don't take it personally and get offended. If patients don't change, don't feel like you've failed.


Problems arise in 3 main areas. Ask:



Systems Change

Change grows best when there is a safe space for it to grow. We need to develop and protect this space for others.

It has been said that when changing systems, both a top-down and grassroots cooperation are required.


With big change, timing is of incredible importance. Change can be slow or fast, depending on circumstances.


Look for clarity within the process of chaos (chaordic theory)


Do your homework and make action fly.